Eugene School District 4J
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1 This enrollment form is a legal document. The information you provide must be accurate and complete. This information is protected by the Family Educational Rights and Privacy Act (FERPA). Student Demographic Information Enter Date: / / 4J Perm ID: Student s Legal Name: Legal Last Name Legal First Legal Middle Suffix Grade (starting at this school): Gender: Female Male Home Language: 1. Which language did this student learn first? English (Other) 2. Which language does this student most often use at home? English (Other) 3. Which language do parents most often use at home? English (Other) 4. Has this student attended school in any other country? No Yes: (Country) a. If yes, when did this student begin school in the US? / / Month Day Year b. If yes, what grade level did he/she complete? c. If yes, has this student been in an English Learner program in the US? Yes No d. If yes, when? / / and where? 5. Has your student been out of school for two years or more? Yes No a. If yes, are you concerned that your student is not at grade level in reading or math? Yes No Birth Certificate Birth Date: / / Birth Verification: Passport (Bring 1) Adoption papers Birth City: Court Order Birth State: Individual Tax ID Number (ITIN) card Birth Country: Matricula Consular card Ethnicity: Hispanic Non-Hispanic Race: White (ancestors from Europe) Asian Native Hawaiian or Pacific Islander (Mark all that apply) Black or African American American Indian or Alaska Native Non-US Native American (ancestors from Mexico, Central America, South America or Canada) Student s Home Address: Mailing Address: Same as home address # Address Address (If different than home address) City State Zip City State Zip County by address: Student s Home Phone: Eugene School District 4J Student Enrollment Cell Phone: Address Verification: Bring 1 current document or correspondence from each column (post marked within the last 60 days). Column A Docs Column B Correspondence Documents Property Tax Statement Social Security Administration Financial Institutions (checking/savings) Lease or Rental Agreement Oregon Gov. Agencies Insurance company Documents related to purchase of Utility companies State and Federal Revenue Document residence Credit card bill Paycheck information Pg. 1
2 Parent/Guardian Information Enrolling Parent Photo ID required ODL OR Id Card Passport/Consular Pg. 2
3 Emergency Contacts (Do not re-list parents please.) List only those authorized to pick up your student when parent/guardian cannot be reached. 1st 2nd 3rd 4th (Services contacts, if applicable) ( ) Case Worker Supervisor Phone ( ) Parole Officer Court Phone Student s Doctor: Has Insurance: Yes No Student s Dentist: Phone: ( ) Phone: ( ) Siblings (List all school age brothers, sisters, step and half brothers and sisters of this student living in 4J.) Other Information Previous School: Phone: ( ) Address City State Zip Permissions: (Valid at this school until changed by Parent/Guardian If left unchecked, assumption is YES) Field Trips: My student may participate in all school field trips. Yes No School Directory: My student s information may be printed in a school directory. Yes No School Website: My student may be mentioned or pictured on the school website. Yes No News Media: My student may be seen, interviewed or quoted on television, radio or newsprint. Yes No Photographs: My student s picture may be taken during class or for class activities. Yes No Video: My student may be video taped during class or class assignments. Yes No HIV/AIDS Instruction: My student may be present during HIV/AIDS instruction times. Yes No My student has permission to use a 4J account for school work. Yes No Google Apps: My student has permission to use Google Applications for school work. Yes No Middle and High Schools only: School Year Book: My student may be mentioned or pictured in the School Year Book. Yes No PG-13 Movies: My student may watch movies rated PG-13. Yes No High School only: (By law the district must release to military recruiters the name, address and phone number of high school students, unless your Student, Parent or Guardian notifies the district that they do not want the information released.) I request my student s name/contact information be released to Military Recruiters. Yes No I request my student s name/contact information be released to College/Coach Recruiters. Yes No Pg. 3
4 Special Services Special Services: Please check all services needed by this student. EL/LEP Services IEP/Special Education Plan Teen & Pregnant Parenting Program Section 504 Plan Talented and Gifted Program Title VII Indian Ed (Natives Program) Speech Services IDEA: Special Education Eligibility/Individualized Education Plan (IEP) Individuals with Disabilities Education Act (IDEA): This is a law ensuring services to children with disabilities. IDEA governs how states and public agencies provide early intervention, special education and related services. Does the student have an Individualized Education Plan (IEP) from another school/district? Yes No * If yes, enter all known data: Prior case manager/contact name: Prior IEP Date: Prior Eligibility Date: Eligibility Category: Title VII: Indian Education Program Office: Fax Yes forms to: Title VII - Indian Education Program: This program serves students who are members of a US federally recognized American Indian Tribe. Through this program students are able to participate in multiple learning activities at no charge. Is this student, parent or grandparent a member of a US federally recognized American Indian Tribe? *If Yes, please fill in the tribe name: Yes No Title I-C: Migrant Education Program Office: Fax Yes forms to: (or courier to LESD) Title I C - Migrant Education Program: This program provides assistance to youth ages 0-21 who move in order for them or their parents/guardians to seek or obtain temporary or seasonal work in agriculture, forestry or fishing. Free services may include summer school, prekinder support, accident insurance, and referrals to community resources. Has your family moved within the last three years? (including short duration moves) Yes No Has a person in your family ever worked or planned to work in agriculture? forestry? fishing? Yes No McKinney-Vento Program Office: Fax checked form to: McKinney-Vento Program: This program guarantees that students, no matter their living situations, have access to public education. Program resources may include transportation assistance, school supplies and other services to help ensure success in school. Please check the box that applies: You are sharing the housing of other persons due to economic hardship or other similar reason. You are staying in a motel or hotel due to economic hardship or similar reason. You are staying in a car, RV, campsite, or substandard housing. You are staying in a shelter. Special Circumstances Is this student currently suspended? No Yes School and Address Is this student currently expelled? No Yes School and Address Signature: I declare that the above information is true to the best of my knowledge and belief. I understand that I commit the crime of false swearing if I make a false statement, knowing it to be false. (ORS ). Furthermore, I understand that my student could be returned to their neighborhood school upon determination of a false address. Parent/Guardian Name: Date: For Office only: Student Name: Perm ID: (Please Print) School Name: (Please Print) Revised Pg. 4
5 General Medical Profile (Complete for Health Staff and Health Folder) Student Name: Birthdate: / / Grade: Doctor/Phone: Dentist/Phone: Primary Caregiver: Phone #s Medical Conditions: History of Surgery/Severe Injury/Concussion: Check if your student has any of the following? If your student has any of the conditions with an asterisk*, ask office staff for that condition form. Allergies food: Allergies insects: Allergies seasonal: Allergies misc: Anaphylaxis Last episode: Asthma* Diabetes* Heart Problem* Seizure Disorder* Other: Physical Condition Check if Epi Prescribed Therapy/Interventions Behavioral Condition Therapy/Interventions Speech Condition Speech Therapy/Interventions ADD/ADHD Frequent Ear Infections Fainting Vision Condition Wears glasses Wears contacts Hearing Condition Hearing Aids/devices Has Insurance Current Medication/s Dose/s Time/s Taken For Student Needs at school: My student requires Medication at school (daily/as needed/emergency): A separate Medication Authorization Form is required for each medication to be given at school and for changes in dosage or time of administration. My student requires Medical/Nursing Assistance at school: MM My student has Physician-Ordered Food Restrictions: My student has Physician-Ordered Activity Restrictions: There is not a licensed nurse in the building at all times. Please direct any medical correspondence, changes of school medical orders or prescriptions for your student to the nurse at your student s school. Please keep emergency contacts updated with the school office. Parent/guardian must bring any medication your student requires at school in the original, labeled container (with Rx for prescription medication). The information on this form will be kept in your student s health file and will be shared with school staff as needed in the interest of your student s well being, safety and education. Parent Signature: Date:
6 REQUEST FOR STUDENT RECORDS Last School Attended: Street Address: City, State, Zip: Telephone: Fax: Student(s) Name: Birth Date Grade Please send complete information about student(s) by forwarding the following records to the address indicated below on this form within ten (10) days of receipt of this request. Cumulative Folder (attendance records, grade level, classroom test results, grades) Health record folder (hearing, vision, immunizations, etc.) If from a state other than Oregon, please include the Certificate of Immunization All Special Education records Please fax the following immediately to : Current IEP Current eligibility statement(s) Most recent evaluation report/assessment results Psychological Testing (educational, social, developmental information) Behavioral Records Other special program records (TAG, FARMS, Title 1, etc.) In accordance with the Family Education Rights and Privacy Act of 1974 and Oregon State law, I hereby authorize the release of all records on the student(s) listed above to the below referenced school. *Please note: Federal Law requires no parent signature for educational records to be sent to another agency. Signature of secretary/school designee* Signature of parent or guardian Date Date of Enrollment at new school:. Parent Notification: Under Oregon law, you have the right to review your student s records, to request an amendment of specified content and to request a hearing if the school district does not agree to amend the records. Send Records to: School Address Eugene, OR 9740_ (541) 790-#### Rev 8/2014
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